Updated on 12/3/24. Originally published as a guest post from David Fidler, VP, eServices at CRx on Drug Channels.
With 51% of physicians reporting that prior authorizations (PAs) for prescribed branded and specialty medications have significantly expanded over the last five years, PA requirements continue to be a major hurdle for patients and healthcare providers (HCPs) alike.
Delaying medication approval by even a few hours impedes patient access to treatment and increases the risk of abandonment. Despite calls to reform our current PA system in order to reduce administrative burdens on HCPs and staff and lessen patient waiting time, there is little indication that changes will happen any time soon.
So how can pharma brands help overcome this roadblock in order to better support patient adherence and keep their first-choice status with HCPs?
Navigating Prior Authorization: Pharma's Role in Streamlining the Process
As HCPs and patients know, responses to traditional PAs can take days, even weeks. Conversely, electronic PAs (ePAs) can be determined in just a few minutes when the required information is submitted quickly and the decision is straightforward. As a result, the increasingly widespread use of ePAs is significantly improving adherence.
When approval is not a simple matter, however, things can get tricky. The retrospective ePA process, which triggers the need for a PA upon denial at the pharmacy, all too often leaves patients, pharmacists, and prescribers stuck in a sort of limbo due to uncertainty a PA is even being requested. Any administrative delay in the process - prescribers being unaware that a PA is needed, pharmacies not knowing a PA is being pursued, patients seeing the full cost of the medication, for example - may leave patients with no choice but to walk away without their prescription. In other words, the increasing implementation of the ePA process certainly helps, but it is not enough, alone, to solve the PA dilemma.
A comprehensive first-fill buy-down co-pay program, in which brands offer to buy down the first fill of a patient’s medication before approval is received, in combination with the ePA process has the potential to solve this problem, based on recent case studies reviewed by ConnectiveRx, helping patients to leave the pharmacy with their prescribed medication.
It is widely recognized that patient savings programs greatly increase access and adherence for branded and specialty medications. In fact, recent market research shows an 11.5% script lift when patient savings options are offered. So when brands are challenged with the task of supporting patient adherence while also maintaining profitability and market share, the answer may lie in finding innovative ways to use the ePA system.
However, most savings programs are generally available for approved medications, not pending ones. If brands offered to buy down the first fill of a medication before approval is received, the approval process could play out behind the scenes while patients are sent home with their medications - giving prescribers the time they need from an administrative perspective to provide adequate information to the payers to help secure approvals. If the process results in approval, the health insurer will pay their fair share of subsequent fills, and patients are more likely to refill and adhere to their medication, resulting in ongoing revenue for the brand.
Case Study: An Effective First-Fill Copay Strategy Boosts Adherence
ConnectiveRx has tracked ePA initiation status to determine cost vs. revenue. One brand (Brand X) offered a co-pay program that covered the cost of first fills while patients were awaiting PA decisions from their health insurers. Of those, 7,597 refills were subsequently covered as the PAs were approved. Brand X paid out an average of $715.13 for the buy down but just $166.96 for the refills. The buy-down co-pay program cost Brand X just short of $10M altogether; the brand ultimately saved more than $19M on subsequent refills, seeing a significant return on investment.
With so many brand launches today focused on specialty medications, the current trends in PA are not going away. The most critical contributor to both patient health and brand revenue is ensuring patients leave the pharmacy with their prescribed medication in hand. Combining ePAs with co-pay programs covering the first fill of medications that require PAs allows sufficient time to overcome administrative hurdles while enabling patients to immediately start therapy. This creates a win-win for brands and the patients who use their medications.
To learn more about ConnectiveRx’s copay ePA program and how it can help improve patient adherence, please visit our Hub Services page for more information. Together, we can work towards streamlining the PA process and supporting patients in achieving better health outcomes through improved adherence to their prescribed medications.